The actual and potential use of various barrier methods for contraception and prevention of sexually transmitted infections (STIs) is the focus of this issue of Network. Male condoms — when used consistently and correctly — are an effective means of preventing HIV infection, gonorrhea (in men) and unplanned pregnancy among people who are sexually active and need to protect themselves. In various settings, promotion of 100 percent condom use has contributed to marked reductions in STI rates. However, accurate messages about condoms must build on (and not substitute for) a wide range of STI risk-avoidance and risk-reduction approaches. The issue also discusses female condom reuse issues and various strategies that offer dual protection against both unplanned pregnancy and STIs. Another highlight is an overview of the status of research on various microbicides that might be used topically as protective barriers against HIV and other STIs. Finally, the issue explores the soon-to-be tested hypothesis that diaphragms offer women some protection against STIs.
In this issue
The "ABC to Z" Approach
Male condoms — when used consistently and correctly — are an effective means of preventing HIV infection and unplanned pregnancy among sexually active individuals who need to protect themselves. However, they are only one element in a comprehensive approach to the prevention of HIV and other sexually transmitted infections (STIs.) For example, the term "ABC approach" refers to the strategy of: abstinence, be faithful to one partner, or — if "A" or "B" cannot be achieved — use condoms. This ABC approach defines an appropriate role for condoms as an essential part of a larger armamentarium for HIV prevention. In fact, a broader "ABC to Z" model is suggested in this article to convey the full spectrum of prevention opportunities.
Targeting Populations at Increased Infection Risk
Traditionally, efforts to prevent HIV infection by promoting condom use — as part of a comprehensive array of risk reduction approaches — have targeted people at increased risk of infection. These include sex workers based in brothel establishments, as well as those based in non-brothel establishments (where condom use often is low), and men, since they often make the final decision on condom use in sexual settings. Campaigns with Uniformed Services Change Behaviors describes the success of 100 percent condom use programs implemented in brothels, while also recognizing the contribution of a uniformed services peer education program that promotes condom use and delivers other HIV prevention messages. Public Health Initiative Nearly Halves STI Rates explains the nature of a condom promotion initiative in the Dominican Republic. Finally, Measuring Condom Use Better explores why and how researchers are seeking ways to more accurately measure the consistency of condom use.
Female Condom Reuse Issues Explored
For female condom users, use of a new female condom for every act of sexual intercourse is recommended by the World Health Organization (WHO). However, reuse may be acceptable, feasible, and safe in some circumstances, leading WHO to state that "the final decision on whether or not to support reuse of the female condom must ultimately be taken locally." WHO recommends that, on the local level, program managers not recommend female condom reuse until they have adapted a female condom cleaning and handling protocol (retaining all procedural steps) to local conditions and then tested the protocol's feasibility, efficacy, and usefulness in their settings.
Dual Protection
Continuing research and discussion on the two major strategies for dual protection against both unplanned pregnancy and sexually transmitted infections (STIs) indicate that each strategy has distinct advantages and disadvantages, as depicted in the table Dual Protection Strategies, and that appropriate dual protection messages may differ according to individual circumstances. Emphasizing Dual Protection Messages describes how such messages are being integrated into reproductive health services in such locations as Nigeria, Ethiopia, South Africa, and Kenya. That consistency of condom use may depend at least as much on individual characteristics as on whether a condom-only or a dual method approach to dual protection is used is discussed in Dual Protection and Consistency of Condom Use.
After N-9, What Next?
More than 50 agents are being studied for their potential as microbicides that might be used topically as protective barriers against HIV and other sexually transmitted infections (STIs). While a microbicide is unlikely to reach the market until after 2010, six microbicide products are expected to enter effectiveness trials in 2003 and 2004. The ways in which those products act to prevent HIV and other STI pathogens from infecting cells is depicted in Microbicides Approaching Effectiveness Trials: How They Work. Meanwhile, although nonoxynol-9 (N-9) remains a moderately effective contraceptive option for women at low risk of HIV infection, N-9 Not for Women at High Risk of HIV Infection explains why N-9 spermicides should not be used by other individuals or for other purposes.
Will Diaphragms Protect against STIs?
The hypothesis that diaphragms might offer women some protection against sexually transmitted infections (STIs), including HIV, will soon be tested in several randomized controlled trials. Also to be explored soon is the question of whether diaphragms and microbicides would be more effective in preventing STIs if they were used together. The status of the Today contraceptive sponge — an alternative to the diaphragm — is discussed in Contraceptive Sponge Re-enters the Market.
